1. Query-based exchange - every country in the world that I've advised (Japan, China, New Zealand, Scotland/UK, Norway, Sweden, Canada, and Singapore) has started with push-based exchange,replacing paper and fax machines with standards-based technology and policy. Once "push" is done and builds confidence with stakeholders, "pull" or query-response exchange is the obvious next step. Although there are gaps to be filled, we can and should make progress on this next phase of exchange. The naysayers need to realize that there is a process for advancing interoperability and we'll all working as fast as we can. Query-based exchange will be built on top of the foundation created by Meaningful Use Stage 1 and 2.

2. Billing - although several reports have linked EHRs to billing fraud/abuse and the recent OIG survey seeks to explore the connection between EHR implementation and increased reimbursement, the real issue is that EHRs, when implemented properly, can enhance clinical documentation. The work of the next two years as we prepare for ICD-10 is to embrace emerging natural language processing technologies and structured data entry to create highly reproducible/auditable clinical documentation that supports the billing process. Meaningful Use Stage 1 and 2 have added content and vocabulary standards that will ensure future documentation is much more codified.

3. Safety - some have argued that electronic health records introduce new errors and safety concerns. Although it is true that bad software implemented badly can cause harm, the vast majority of certified EHR technology enhances workflow and reduces error. Meaningful Use Stage 1 and 2 enhance medication accuracy and create a foundation for improved decision support. The HealtheDecisions initiative will bring us guidelines/protocols that add substantial safety to today's EHRs.

4. Privacy and Security - some have argued that EHRs reduce security by making records available in electronic form, possibly over internet connections. Efforts to enhance certification of the security of EHRs, encrypt data at rest, and create guidance for EHR modules that interoperate with built in security will further protect the data that needs to be shared for care coordination and population health.

5. Innovation - some have argued that meaningful use led to the growth of a small number of vendors and dependency/lock in with those vendors. Meaningful Use Stage 2 requires interoperability between vendors, export of data from EHRs to reduce lock in, and standards that will enable a new generation of modular "plug ins". I'm confident that SHARP grant funded work, like the SMART initiative will lead to an ecosystem of applications from small vendors - an app store for health.

Thus, our mantra should be that Meaningful Use Stage 1 and 2 have created a foundation for query-based exchange, accurate billing, safety, security, and innovation.

Stage 3 work is already in progress and from the early thinking that I've seen (will post a blog about that in a few weeks), the trajectory of Meaningful Use will address all the naysayers concerns.